Online Health Chat with Joseph Nally, MD
March 13, 2013
Being diagnosed with Chronic Kidney Disease brings on many lifestyle changes – and it can be overwhelming. The most important steps are to become informed about those lifestyle changes and to ask as many questions as possible regarding your treatment options.
A number of diseases, including diabetes and high blood pressure, can prevent your kidneys from functioning at their best. In addition to having these conditions, the risk of chronic kidney disease is also higher in those with a family history of the disease and in those who often use painkillers, including over-the-counter drugs such as aspirin and ibuprofen. Kidney diseases occur when the nephrons in the kidney are damaged and cannot filter the blood. This damage can be suddenly caused by injury or toxin, or may occur over a period of time due to disease.
When kidney function steadily worsens—chronic kidney disease, or CKD—waste builds up in the blood. Symptoms may include a feeling of tiredness, a change in how often you need to urinate, numbness, itchiness and darkening of the skin. You can become anemic and develop weak and brittle bones. CKD also increases the risk of stroke and atrial fibrillation.
CKD is managed as long as possible with medications and a special diet. As the disease progresses, however, you may require a dialysis or a kidney transplant. If a transplant is required, careful matching of blood and tissue is performed. The kidney may come from a living or deceased donor.
Early detection and appropriate treatment are important in slowing the disease process, with the goal of preventing or delaying kidney failure.
For More Information
On Cleveland Clinic
Cleveland Clinic's Department of Nephrology and Hypertension has a long history of significant expertise in acute and chronic renal failure. The department offers services in the areas of chronic kidney disease, hypertension, dialysis, kidney transplantation and renal diseases.
Our staff works in a care team model to provide increased availability to physicians and timely consultations for patients. As part of the Glickman Urological and Kidney Institute, the Department of Nephrology and Hypertension is aligned with the departments of Urology and Regional Urology, enabling us to better serve patients in the prevention, diagnosis and treatment of kidney disease.
The Glickman Urological and Kidney Institute at Cleveland Clinic is ranked first in the nation for nephrology by U.S.News & World Report of the nation’s best hospitals 2012-2013.
For more information about kidney conditions, treatment and The Glickman Urological and Kidney Institute, please visit http://my.clevelandclinic.org/urology/default.aspx.
On Your Health
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A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult
To make an appointment with Dr. Nally, or any of the other nephrologists in the Glickman Urological & Kidney Institute at Cleveland Clinic, please call 216.444.6771 or call toll-free at 800.223.2273, ext. 46771. You can also visit us online at www.clevelandclinic.org/Glickman
About the Speakers
Joseph Nally, MD, is a board-certified nephrologist in the Department of Nephrology and Hypertension within the Glickman Urological and Kidney Institute at Cleveland Clinic. Dr. Nally is Director of the Chronic Kidney Disease program at the Cleveland Clinic, in addition to being a staff physician in the Transplantation Center. His interests include chronic kidney disease, renal disease and transplantation, hypertension and renovascular disease.
Dr. Nally completed his fellowship in nephrology at the Medical College of Pennsylvania Hospital, in Philadelphia, following completion of his residency in internal medicine at The Ohio State University Hospitals, in Columbus, Oh. He is a medical school graduate of The Ohio State University College of Medicine and Public Health.
Let’s Chat About: Get the Facts on Chronic Kidney Disease
Joseph_Nally,_MD: Welcome to our web chat on kidney disease. My name is Dr. Joe Nally and I am a nephrologist (or kidney specialist). I am the director of Cleveland Clinic’s Center for Chronic Kidney Disease. I am happy to do this web chat on the eve of World Kidney Day 2013, which is March 14th. This is the eighth annual World Kidney Day, and the overall theme is to recognize that kidney diseases are common and harmful, yet treatable.
Chronic Kidney Disease and Polycystic Kidney Disease Diagnosis
csengelh: Can you please describe differences between chronic kidney disease (CKD) and polycystic kidney disease? As a patient, I have been given conflicting information on dietary restriction, medication and the progression of my disease. Are they significantly different from one another?
Joseph_Nally,_MD: Polycystic kidney disease is one type of CKD. Polycystic kidney disease (PKD) is inherited. Affected parents may pass on the gene to half of their children, which can result in renal cysts and eventual worsening of kidney function by midlife in those children affected. Patients with more advanced PKD should follow the same dietary restrictions. In addition, caffeine should be avoided since it may contribute to the growth of the cysts.
With respect to medications, several interventions for PKD have recently been studied. One study of antihypertensive agent drugs suggests that the best choice of agents may be ACE (angiotensin-converting enzyme) inhibitors or ARBs (angiotensin receptor blocker). Other studies that are examining the effects of the immunosuppressant drug Rapamune® (sirolimus) and the ‘vaptan’ (vasopressin antagonist) drugs, such as Samsca® (tolvaptan), are in progress with results that are only modestly encouraging.
Current therapy advocates ACE and ARBs for blood pressure control and avoiding potential nephrotoxins such NSAIDS (nonsteroidal anti-inflammatory drugs) or IV contrast for x-ray studies.
Studies examining the progression of PKD are difficult to conduct since PKD tends to progress quite slowly over the years. Therefore, it is difficult to prove the benefits of certain therapies—but the slow progression is great news for PKD patients! Investigators continue to hope for gene therapy in the future.
kazba: What are the chances of developing chronic kidney disease (CKD) due to taking blood pressure medications for over 20 years?
Joseph_Nally,_MD: The leading causes of CKD in the U.S. are diabetes mellitus and hypertension. It is recommended that any patient with either diabetes or hypertension be screened for CKD with blood tests for serum creatinine and estimated GFR and a urine test for proteinuria or albuminuria. Some patients with primary hypertension may have long standing hypertension, yet never develop significant CKD. But why guess? Please talk to your doctor about obtaining the two tests for CKD outlined above. Since CKD is a silent disease, only blood and urine testing can determine if you have developed CKD after 20 years of hypertension treatment.
Progression of Chronic Kidney Disease
neptune: I was diagnosed with chronic kidney disease around five years ago. My creatine has remained constant at 1.4 to 1.5 on blood tests over the years. Could I assume that the disease will not progress? I am in my 70s. I monitor my intake of phosphorous, potassium, sodium and protein.
Joseph_Nally,_MD: Congratulations on the stability of your CKD Stage 3! I predict that it is likely that you have little to no protein or albumin in your urine. Over the last few years, we have learned that the absence of albuminuria suggests slow progression in older patient with CKD Stage 3, like you. I would continue your diet as it has been successful to date, but I suspect that you have more than adequate kidney function, such that significant reduction in proteins, phosphorus and potassium may not be needed. Dietary sodium restriction is recommended in patients who may have hypertension with or without CKD.
Baltimore: Is there currently any substitute for dialysis procedure for chronic kidney failure?
Joseph_Nally,_MD: With advanced chronic kidney disease (CKD) with a glomerular filtration rate (GFR) less than 10 and uremic symptoms, patients may require renal replacement therapy, such a dialysis or renal transplantation. There are two types of dialysis. In hemodialysis the blood percolates through an artificial kidney for four hours on a schedule of three days per week. The alternative dialysis procedure is peritoneal dialysis where fluid is cycled through the abdomen via an external catheter nightly. The optimal treatment for end-stage renal disease is renal transplantation in an otherwise healthy patient. The best option is for a live donor transplant with a family member such as a parent or sibling. Living unrelated donor transplants may be performed with spouses, friends, cousins, and so on. If no live donor is available, a patient may be placed on the deceased donor waiting list. I would encourage all patients with advanced CKD and a GFR less than 20 to request a referral to a kidney transplant program in order to consider their transplant options.
Treatment of Renal Artery Stenosis
roystabe: What is the recommended treatment for renal artery stenosis?
Joseph_Nally,_MD: Our thoughts on the optimal treatment for renal artery stenosis have evolved over the last several years based upon the results of several randomized control trial studies comparing medical therapy to intervention with renal artery stenting. Originally, we had hoped that stenting would improve both blood pressure control and kidney function. Unfortunately, the results of the trials have not supported this theory. Several clinical study trials, such as DRASTIC (Dutch Renal Artery Stenosis Intervention Cooperative study), ASTRAL (Angioplasty and Stenting for Renal Artery Lesions), and other studies, showed that stenting did not provide benefit over standard medical therapy. The final trial study CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) results will be available soon—which is also likely to have negative results. Hence, current therapy favors attentive antihypertensive care with aggressive modification of cardiovascular risk factors. Certain select patients may still benefit by referral to a hypertension specialist for consideration of occasional renal artery stenting.
hamodhabeby: I am a professor of urology in Egypt. I have had stage 3 chronic kidney disease (CKD) for the last two years. Can you arrange for me to have a kidney transplant at Cleveland Clinic? Also, as a Muslim I have participate in Ramadan fasting for 30 days. Will this be possible?
Joseph_Nally,_MD: First of all, a kidney transplant evaluation with CKD Stage 3 may be premature. I would recommend delaying kidney transplant evaluation until you are Stage 4 with a glomerular filtration rate (GFR) less than 30. If you would like more information on our kidney transplant services, please visit www.clevelandclinic.org/kidneytransplant .With Stage 3 kidney disease you should have adequate kidney function to participate in the Ramadan fast.
Kidney Function After Organ Transplant
Weemer: It has been eight years since my liver transplant at Cleveland Clinic. Recently, my creatinine level has gone up from a steady 1.4 to a 1.8. I am on an anti-rejection drug called Prograf® (tacrolimus), but Cleveland Clinic has reduced my Prograf® level. Do you think Prograf® affects kidney problems?
Joseph_Nally,_MD: Liver transplant patient on immunosuppressive drugs known as calcineurin inhibitors, like cyclosporine or Prograf®, may develop kidney problems just like you have described. Our initial approach is to reduce the Prograf® dose and follow blood levels to achieve the lowest acceptable Prograf® level. An alternative strategy would be to switch the patient off Prograf® to another immunosuppressive drug such as Rapamune® (sirolimus), which does not have these nephrotoxic side effects.
kawelch21: It has been 10 years since my heart transplant, and I have been diagnosed with stage 4 chronic kidney disease (CKD). My last laboratory tests were creatinine 1.93. BUN 47 and GFR 27. My hemoglobin and hematocrit are 10.2 and 32. I was seen by nephrology in July, and was told I would probably need a kidney transplant within a year. My GFR has been as low as 24. I have not been seen by them again. I requested an appointment and will be seen on March 14. I haven't received any nutrition advice and been advised on what to do about live donors. I feel lost!
Joseph_Nally,_MD: These are all great questions for someone in your situation, as a heart transplant recipient who now has significant CKD. I am delighted that you will have the opportunity to have one of our nephrologists address all of your great questions in detail tomorrow on World Kidney Day 2013.
Chronic Kidney Disease Diet
Sscott486: My husband is on the line between stage 3 and stage 4 kidney disease. We've been told to keep his potassium level below 2000 per day, but many foods do not list potassium levels. Furthermore, we've cut way back on fresh salads and vegetables. The doctor took him off his multivitamin that contains potassium. Aside from the fact he's really missing fresh salads, I'm concerned about nutrition without the fresh vegetables and fruits. Do you have any ideas? Am I right to be concerned about nutrition?
Joseph_Nally,_MD: Dietary therapy can be an important component in the care of patients with advanced chronic kidney disease (CKD). Nearly all CKD patients should be on a low sodium diet with exercise and optimal weight management to keep their blood pressure under good control. In addition, a patient with Stage 4 and 5 CKD should moderate their protein and potassium intake. If serum potassium begins to rise, significant dietary potassium reduction may be required. Many of the foods that you mentioned are on the list of high potassium foods that need to be restricted. A more complete list can be obtained through the National Kidney Foundation website (www.kidney.org) to help you and your husband guide his low potassium diet. Furthermore, a consultation with a renal dietician may be helpful to help reduce his dietary protein and potassium intake.
Cleveland Clinic’s International Center
shahruh77: I have a chronic kidney disease (CKD). I am from Uzbekistan (which is in Central Asia). Doctors here could not provide me with an exact diagnosis. Last year I went to China to undergo tests to establish a kidney diagnosis. However, they could not provide me with an exact diagnosis either. As a foreigner, is it possible for me to get testing done in the United States in order to get a definite diagnosis of my chronic kidney disease? How much would that cost?
Joseph_Nally,_MD: This is a great first question as we celebrate World Kidney Day 2013. The celebration is international and involves nearly 150 countries worldwide. A patient is determined to have CKD based upon two simple tests. A blood test for serum creatinine is needed to calculate GFR (glomerular filtration rate) ,and urine tests are needed for albumin or protein in the urine. This information establishes CKD as a diagnosis, but further studies are needed to determine the cause of CKD. The most common causes of CKD in our country are hypertension, diabetes mellitus and cardiovascular disease. A kidney biopsy is required for a diagnosis of glomerulonephritis. In fact, a type of glomerulonephritis called IgA nephropathy is the most common cause of advanced CKD and end-stage renal disease in the Pacific rim. China is one of the many countries participating in World Kidney Day 2013, and nephrologists in many major medical centers there should be able to make a precise diagnosis. There are options for international patients here at Cleveland Clinic for an online consultation via MyConsult in which one of our experts reviews your medical records and makes suggestions for diagnosis and management. A second alternative is to contact Cleveland Clinic’s International Center to arrange a visit for a formal face-to-face consultation. The International Center can be reached by calling toll-free 800.223.2273. They should also be able to provide you with information about the costs of the consultative services.
Moderator: I'm sorry to say that our time with Cleveland Clinic expert Joseph Nally, MD is now over. Thank you Dr. Nally for taking your time to answer our questions today about chronic kidney disease.
Moderator: Thanks you for your interest and participation today. For additional information you may download the Cleveland Clinic Chronic Kidney Disease Guide.
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